Susan Dentzer: It is time to move past denying the perfect storm facing U.S. healthcare

The phrase “a perfect storm” has been around for some time, but it is most closely associated today with a meteorological event that exploded in the northern Atlantic in the autumn of 1991. The event resulted from a convergence of storms — a hurricane from Bermuda, a Canadian cold front and a Great Lakes nor’easter that collided over the Grand Banks fishing grounds off Newfoundland, Canada. Weather alerts a few days beforehand signaled the dangers to ships — predictions of waves, for example, that eventually surged 10 stories high. But a Massachusetts-based fishing boat trawling the area in search of swordfish, the Andrea Gail, didn’t respond quickly enough and sank, killing its crew.

In his best-selling book about the catastrophe, noted author Sebastian Junger, with some understatement, wrote: “There’s a certain amount of denial in swordfishing.”^a

Healthcare’s warning signs

There’s a certain amount of denial in healthcare as well, which helps to explain why both the system and national healthcare policy are only now waking up to long-developing strains. Consider the following elements of this perfect storm, most of which have been building for at least 70 years.

Aging patients. The leading edge of the baby boom generation (born 1946-1964), estimated to number about 70 million in 2023, will reach 80 in just two years, at which point the youngest will be 62.^b Nearly all adults in the 65-plus age group have at least one chronic condition, and four in five have two or more.^c The number of adults ages 60 and older with more than two chronic conditions is projected to rise 66%, to nearly 11 million, between 2020 and 2035.^d To state the obvious, these long-lasting ailments typically require regular office visits, lab tests, prescriptions and medication checks — and, if poorly or episodically treated, can lead to costly emergency department visits and hospitalizations.

Rising costs. Healthcare utilization and spending rises with age; for example, physician office visit rates for those 65 and older are more than twice the average for all age groups and exceeded only by the rate of visits for children under age 1.^e Medicare Advantage (MA) plans have recently seen surges in utilization that appear at least in part to be related to enrollees’ advancing age and illness. These and other cost pressures are already leading to the highest projections of medical cost trend growth in 13 years. Meanwhile, affordability has already reached a crisis point for many Americans, including older adults. One model has projected that the median older adult will spend 40% or more of income on healthcare (point-of-care costs plus premiums) by 2035.^f

Aging providers. The healthcare workforce is itself aging; as of 2021, nearly half of active U.S. physicians were age 55 and older.^g Meanwhile, despite some growth — mainly coming from a rising number of advanced practice providers, such as nurse practitioners — the corps of U.S. clinicians in primary care is already “insufficient to meet the demands,” and threatens to worsen, according to one recent report.^h

Dan Liljenquist, chief strategy officer at the 33-hospital Intermountain Health in Salt Lake City, told the audience at a recent America’s Physician Groups conference that a full 25% of Intermountain’s providers are scheduled to retire in the next five to seven years.

“Even if we hired every single provider out of every single program, out of every single school, across nursing, doctors, everybody, and retained all of them, we will be thousands of providers short,” he predicted.

As these storm trends converge, the impact is obvious.

In economic terms, Liljenquist said, there is “a huge shift to the right in demand for services, [and] a shift to the left in supply [of providers] at the same time.”

One result: According to a 2022 AMN/Merritt Hawkins survey, the average wait time to see a physician in 15 U.S. metropolitan markets in 2022 was 26 days, and it was 49 days to see a cardiologist in Portland, Ore., and 72 days to see a dermatologist in Minneapolis.ⁱ

 Liljenquist suggested that, with the exception of high-cost concierge-level care — which even prominent health systems like Johns Hopkins Medicine in Baltimore and Mass General Brigham in Boston are now touting — it seems increasingly likely that the traditional one-to-one physician-to-patient relationship may soon be a thing of the past for the bulk of less well-off Americans.

4 responses are imperative

How can the healthcare sector respond — in effect, to rebuild healthcare’s “house” to accommodate the rising demand, make life tolerable for increasingly stretched care providers and produce a system that is affordable and financially sustainable for the nation?

Here are the four most-needed responses.

1 Flip the predominant payment model in healthcare from rewarding sick care toward incentivizing preventive care. This shift also means a move away from classic fee-for-service payment — which is still skewed toward rewarding sick care and procedures — to more value-based models. For example, although the MA system is admittedly not perfect, risk-adjustment payments in MA are designed to push payment toward sicker patients. Clinicians working closely with MA plans then have the resources and incentives to make diagnoses early; monitor patients and intervene when necessary; and, overall, provide better longitudinal care — including avoiding unnecessary hospital use, still the highest-cost component of healthcare.

2 Make more use of information and technology to better understand patients and their holistic care needs. By so doing, providers can direct patients to the most appropriate source of care at any given time, including vital assistance from social services agencies. The process can be systematized through predictive analytics that combine clinical and claims data with other critical information about patients, such as education levels, finances, housing stability, food needs, access to transportation and proximity to relatives who can assist with care.

Working toward these ends, Intermountain has partnered with the venture-capital-backed health technology firm Unite Us to power a community collaborative of social services providers convened and funded by the health system.^j

3 Push healthcare out of hospitals and physician offices to deliver far more virtual care and home care. This step necessarily includes enlisting the help of patients and their caregivers in providing more self-care along the way.

“The future of healthcare is actually in the home,” Maria Ansari, MD, CEO of the Permanente Federation, told the audience at the previously mentioned America’s Physician Groups conference. The Permanente Federation represents the eight medical groups and 24,000 physicians affiliated with the giant Kaiser Permanente system. Kaiser has built a robust technology platform to conduct 22 million phone and video visits in 2023 and deliver hospital-level care at home, 24/7. Among other positive outcomes, a study of Kaiser patients “hospitalized” at home for conditions such as heart failure showed that they were two-thirds less likely to suffer delirium than conventionally hospitalized patients.^k Elsewhere, studies suggest considerable cost-saving potential in shifting care from hospitals to other sites.^l

4 Create sustainable care teams that support the work of physicians and advanced practice providers. These teams should include allied health professionals, care navigators and coordinators, pharmacists, social workers and community health workers, among others. Even as more patients are supported at home via such diverse care teams, Kaiser’s Ansari said it may be necessary to rethink the care of the highest-needs patients. It may be optimal to have one physician caring for a panel of these patients as small as 200 — versus the average 1,200- to 1,900-patient panel sizes that more typically prevail — and leading teams that will focus on these patients’ holistic needs.^m

Members of America’s Physician Groups, including ChenMed (based in Miami and with locations in 15 states) and Oak Street Health (with locations in two dozen states, and now part of CVS’s Healthspire division) have already embraced this model and have launched training programs to prepare primary care clinicians for these new leadership roles.ⁿ

In short, the time for denial is long past. Tearing down the existing house of medicine and rebuilding it for the aging future is the only viable path ahead. 

Footnotes

a. Junger S., The perfect storm: A true story of men against the sea, New York: W. W. Norton, 1997.
b. Statista, “Resident population in the United States in 2023, by generation,” 2024.
c. National Council on Aging, “Get the facts on healthy aging,”  April 16, 2022.
d. Ansah, J.P., and Chiu, C.T., “Projecting the chronic disease burden among the adult population in the United States using a multi-state population model,” Frontiers in Public Health, Jan. 13, 2023.
e. Ashman, J.J., Santo, L., and Okeyode, T., “Characteristics of office-based physician visits, 2018,” National Center of Health Statistics Data Brief No. 408, May 2021.
f. Hatfield, L.A., Favreault, M.M., McGuire, T.G., and Chernew, M.E., “Modeling health care spending growth of older adults,” Health Services Research, February 2018.
g. Association of American Medical Colleges, 2022 physician specialty data report: Executive summary, January 2023.
h. Jabbarpour, Y., et al., The health of U.S. primary care: 2024 scorecard report — no one can see you now, Milbank Memorial Fund, Feb. 28, 2024.
i. AMN Healthcare and Merritt Hawkins, 2022 survey of physician appointment wait times and Medicare and Medicaid acceptance rates, 2022.
j. Unite Us, “Intermountain Healthcare selects Unite Us to digitally connect medical and social service providers,” Press release, March 13, 2019.
k. Mashaw, A., and Johnson, E., “Advanced care at home at scale in an integrated health care system,” The American Journal of Managed Care, Dec. 19, 2023.
l. Sahni, N.R., Marine, C., Cutler, D.M., et al., “Potential U.S. health care savings based on clinician views of feasible site-of-care shifts,” JAMA Network Open, Aug. 14, 2024.
m. Raffoul, M., Moore, M., Kamerow, D., and Bazemore, A., “A primary care panel size of 2,500 is neither accurate nor reasonable,” Journal of the American Board of Family Medicine, July 7, 2016.
n. Velasquez, D.E., Aung, K., and Khan, A., “Training primary care physicians in for-profit, value-based care clinics,” Journal of General Internal Medicine, Nov. 27, 2023.